School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan 430030, China.
Int J Environ Res Public Health. 2018 Dec 13;15(12):2839. doi: 10.3390/ijerph15122839.
As the principal means of reimbursing medical institutions, the effects of case payment still need to be evaluated due to special environments and short exploration periods, especially in rural China. Xi County was chosen as the intervention group, with 36,104, 48,316, and 59,087 inpatients from the years 2011 to 2013, respectively. Huaibin County acted as the control group, with 33,073, 48,122, and 51,325 inpatients, respectively, from the same period. The inpatients' information was collected from local insurance agencies. After controlling for age, gender, institution level, season fixed effects, disease severity, and compensation type, the generalised additive models (GAMs) and difference-in-differences approach (DID) were used to measure the changing trends and policy net effects from two levels (the whole county level and each institution level) and three dimensions (cost, quality and efficiency). At the whole-county level, the cost-related indicators of the intervention group showed downward trends compared to the control group. Total spending, reimbursement fee and out-of-pocket expense declined by ¥346.59 ( < 0.001), ¥105.39 ( < 0.001) and ¥241.2 ( < 0.001), respectively (the symbol ¥ represents Chinese yuan). Actual compensation ratio, length of stay, and readmission rates exhibited ascending trends, with increases of 7% ( < 0.001), 2.18 days ( < 0.001), and 1.5% ( < 0.001), respectively. The intervention group at county level hospital had greater length of stay reduction (¥792.97 < 0.001) and readmission rate growth (3.3% < 0.001) and lower reimbursement fee reduction (¥150.16 < 0.001) and length of stay growth (1.24 days < 0.001) than those at the township level. Upgraded case payment is more reasonable and suitable for rural areas than simple quota payment or cap payment. It has successfully curbed the growth of medical expenses, improved the efficiency of medical insurance fund utilisation, and alleviated patients' economic burden of disease. However, no positive effects on service quality and efficiency were observed. The increase in readmission rate and potential hidden dangers for primary health care institutions should be given attention.
作为医疗机构的主要补偿方式，按病种付费的效果仍需评估，尤其是在中国农村地区，由于特殊的环境和较短的探索时期。选择 Xi 县作为干预组，2011 年至 2013 年的住院患者分别为 36104、48316 和 59087 人。淮滨县作为对照组，同期的住院患者分别为 33073、48122 和 51325 人。住院患者信息由当地保险机构收集。在控制年龄、性别、机构级别、季节固定效应、疾病严重程度和补偿类型后，使用广义加性模型（GAMs）和差分差异方法（DID）从两个层面（全县层面和每个机构层面）和三个维度（成本、质量和效率）衡量变化趋势和政策净效应。在全县层面，干预组的成本相关指标呈下降趋势，与对照组相比。总支出、报销费用和自付费用分别下降了 346.59 元（<0.001）、105.39 元（<0.001）和 241.2 元（<0.001）（符号¥代表人民币）。实际补偿比例、住院天数和再入院率呈上升趋势，分别增加了 7%（<0.001）、2.18 天（<0.001）和 1.5%（<0.001）。县级医院干预组的住院天数减少幅度更大（792.97 元<0.001），再入院率增长幅度更大（3.3%<0.001），而乡镇级医院的报销费用减少幅度更小（150.16 元<0.001），住院天数增长幅度更大（1.24 天<0.001）。与简单的定额支付或封顶支付相比，升级后的按病种付费更加合理和适合农村地区。它成功地遏制了医疗费用的增长，提高了医疗保险基金的使用效率，减轻了患者的疾病经济负担。然而，服务质量和效率没有出现积极的效果。再入院率的增加和对基层医疗机构的潜在隐患应引起关注。
